*
Indicate Mandatory Fields
Proposal Date
08/09/2010
*
Product
--Select Any--
Reliance Life Premier Term 10 Plan
Reliance Life Premier Basic Plan
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Life Assured Full Name
*
Life Assured's
Birth Date
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1980
1981
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1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
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Proposer Name
*
Proposer Date of Birth
1
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31
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
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1961
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1967
1968
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1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
Relationship With Proposer
Self
*
Sex
Male
Female
*
Salutation
--Select--
DR
MISS
MR
MRS
PROF
*
Occupation
--Select Any--
Other
AdminEmployee
Executive
Salesman
Accountant
Clerk
Diamond Cutter
Jewellry Polisher
Chartered Accountant
Lawyers
Software Engi
Hardware Engi
Civil Engi
Manager
Counter Sales Staff
Agents
Advisor
Parlour Owner
Pensioner
Tea Stall
Retired Employee
Pilot
Others
*
Height
in cm(s)
*
Weight
in Kg(s)
*
Term
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
*
Premium Frequency
Yearly
Monthly
*
Annual Income
Education
--Select Any--
Other
BCOM
MCA
BA
MBA
BBA
BCA
*
Bank Name
*
MICR CODE
Find ECS City
*
Installment Premium
*
Sum Assured
First Premium to be paid
*PAN No
*
Income Proof
Form 16
Salary Slip
*
Income Proof
*
Life Assured's Father Name
Purpose of Insurance
Future Protection
Savings
Protection and Savings
Income tax savings
*
Nature of Duties
*
Marital Status
Select
Single
Married
Nationality
Indian
By default , the fund choice is displayed as 100%. Please choose the fund's of your choice.
New Pure Equity
New Money market
New Balance Fund
New Gilt Fund
New Equity Fund
New Pure Debt
New Midcap Fund
New Infrastructure
Fund
New Corporate Bond
New Energy Fund
*
Address1
*
Address2
*
City
*
State
*
Pincode
*
Email
*
Mobile
Phone No
Is your permanent address is same as Communication Address
Yes
No
Permanent Address
*
Address1
*
Address2
*
City
*
State
*
Pincode
Phone No
*
Address Proof
BANK CERT
Bank Sttmt
Elect Bill
EMPL CERT
IncorpCert
LEASE AGR
M&A Assoc
Public Aut
PowerAttny
Ration Crd
TelephnBil
Others
Bank Acct Statement
Banker's Certification
DRIV LCN
Electricity Bill
Employer's Certificate 2Months
Incorporation Certificate
Lease Agrmnt wth Rnt Rcpt 3mth
Memorandum & Articles of Assoc
Others
Power of Attorney
Public Authority Ltr
PAN Allotment Letter
PASSPORT
Ration Card
Telephone Bill
VT ID CD
**
Address Proof
*
ID Proof
PAN Allot
PASSPORT
DRIV LCN
VT ID CD
Army Identity Card
Driving licence bef 18.04.1993
Driving Licence after 18.04.93
DPP/DPS (IF NO AGE PROOF)
Election Identity Card
Employer Certificate
Government Orders
Income Tax Orders
Municipal Birth Certificate
Non Standard - Other Age Proof
Non Std. Hospital/Clinic
Other Insurance Co's Policies
Passport issued after 01.04.86
Passport issued bef.01.04.1986
PAN Card
Ration Card
School Certificate
Self Declaration
Stamped Affidavit
Standard Other Age Proof
Others
**
ID Proof
Age Proof
PAN Allot
PASSPORT
DRIV LCN
VT ID CD
Army Identity Card
Driving licence bef 18.04.1993
Driving Licence after 18.04.93
DPP/DPS (IF NO AGE PROOF)
Election Identity Card
Employer Certificate
Government Orders
Income Tax Orders
Municipal Birth Certificate
Non Standard - Other Age Proof
Non Std. Hospital/Clinic
Other Insurance Co's Policies
Passport issued after 01.04.86
Passport issued bef.01.04.1986
PAN Card
Ration Card
School Certificate
Self Declaration
Stamped Affidavit
Standard Other Age Proof
Others
Age Proof
**
Photograph
Salutation
MR
MISS
DR
MRS
PROF
Name
DOB
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MM
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
YYYY
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
Relationship
Select
Brother
Mother
Father
Sister
Husband
Wife
Payment Mode
Online
Cheque/DD
*
Cheque No/DD
*
Bank
Name
*
Please read the below terms and conditions carefully and then click I agree box to accept the terms and conditions
I Agree
Terms & Conditions
*
Image Verfication
**
Address proof,Id Proof and Photo graph is compulsory. Request you to upload scan copy or Courier Xerox copies of all documents at below mentioned address
"rlife.einsure@relianceada.com" Reliance Life Insurance co. ltd. 6th Floor, Midas, Sahar Plaza,Andheri-Kurla Road, Andheri - E, Mumbai- 400059". Please mention your application number on your each Xerox copy.
Note:
If your Installment Premium is less than or equal to 10000 then only Id proof and photograph is compulsary .